The days and weeks following a hospital discharge are an inherently high-risk time.
As patients’ care transitions from a medical setting to home, medication errors, confusion over discharge instructions, and missed follow-up appointments can often land patients right back in a hospital bed.
These common, but often avoidable, issues became even more worrisome for doctors when the coronavirus crisis hit—lessening the likelihood patients would even be able to make in-person, follow-up visits after leaving the hospital, said Marwa Moussa, MD, associate chief of medicine at NYU Langone Hospital—Brooklyn. In fact, Dr. Moussa discovered a portion of hospital readmissions between late 2019 and late 2020 might have been preventable.
A fellow with United Hospital Fund and Greater New York Hospital Association’s Clinical Quality Fellowship Program at the time, she decided to do something to address these concerns and to prevent medication errors, discharge instruction confusion, and follow up care issues.
“It was right after the first wave, and we wanted a way of having patients with complicated medical histories to have a follow-up,” said Dr. Moussa. “Our purpose was to prevent errors.”
Focusing on the issue as her fellowship capstone project, Dr. Moussa decided to set up a Transitional Care Management (TCM) clinic within the Family Health Centers at NYU Langone.
The clinic allowed doctors to refer patients being discharged from the hospital to the TCM clinic for both virtual and in-person follow-up visits instead of relying on the patient or third-party providers to schedule those appointments.
The option was especially important for patients without a primary care doctor, uninsured or undocumented patients, and those who might struggle to make a visit within 10 to 14 days due to a coronavirus diagnosis or concern.
Plus, hospital staff found it easier and more trustworthy than regular follow-up practices, Dr. Moussa said.
“Little by little, they actually felt a lot more confident ordering a TCM appointment rather than a regular appointment,” Dr. Moussa said. “They knew their peers and colleagues were the ones handling it and could control that hand-off. Everyone started to use it.”
Within months, the number of patients referred to the TCM clinic doubled, from 39 patients in October 2020 to 83 patients in April 2021.
Dr. Moussa credits the jump to a new tool in the electronic system that made it easy for doctors to refer patients. Her team also educated staff about the new clinic.
“It was easy for them—everything that is easy is sustainable,” she said.
The TCM clinic also made a difference in those avoidable readmission numbers. Dr. Moussa found that only 3 percent of patients who completed a TCM visit were readmitted to the hospital after discharge compared to an average of 14 percent of patients not referred to the clinic who were readmitted.
Knowing this, Dr. Moussa set another goal for her project: decreasing no-show rates at the clinic, which were particularly high for in-person visits. She was able to reduce the number of patients who didn’t show up by championing virtual appointments—which had better completion rates—and by asking doctors to discuss the TCM clinic with patients before setting up a visit.
The TCM clinic is still running successfully at NYU Langone Hospital—Brooklyn two years after Dr. Moussa’s fellowship project and has even expanded to treat a new subset of heart failure patients, she said.
That success in large part stems from the Clinical Quality Fellowship Program’s help in brainstorming ideas for the clinic, Dr. Moussa said. The fellowship has even shifted Dr. Moussa’s overall perspective on quality improvement.
“I’m looking to focus more on quality in my career going forward,” Dr. Moussa said. “What I love most about it is making change.”